It used to be that only organizations were held liable for infractions, but it is becoming more and more common for individuals to be held responsible, as well.
First, I would request and review your organization's compliance program. It should include a method for reporting suspected violations. If your company does not have a compliance plan, I would strongly urge you to look for employment elsewhere. A compliance plan is a requirement for any individual or organization that participates in any federally-funded program (i.e. Medicare or Medicaid), and it is just good business practice to have one in any case.
False Claims Act (False Claims Act (FCA), 31 U.S.C. §§ 3729 - 3733)
The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. Knowingly includes having actual knowledge that a claim is false or acting with “reckless disregard” as to whether a claim is false.
In addition to the federal law, some states have adopted similar laws designed to prevent fraud, kickbacks and conspiracies in connection with the Medicaid program.
Examples of false claims include billing for services not provided, billing for the same service more than once or making false statements to obtain payment for services.
Penalties Under the False Claims Act
Violations under the federal False Claims Act can result in significant fines and penalties. Financial penalties to the person or organization includes recovery of three times the amount of the false claim(s), plus an additional penalty of $5,500.00 to $11,000.00 per claim.
The statute provides that one who is liable must pay a civil penalty of between $5,000 and $10,000 for each false claim (those amounts are adjusted from time to time; the current amounts are $5,500 to $11,000) and treble the amount of the government’s damages. Where a person who has violated the FCA reports the violation to the government under certain conditions, the FCA provides that the person shall be liable for not less than double damages.
The Knowledge Requirement
A person does not violate the False Claims Act by submitting a false claim to the government; to violate the FCA a person must have submitted, or caused the submission of, the false claim (or made a false statement or record) with knowledge of the falsity. In § 3729(b)(1), knowledge of false information is defined as being (1) actual knowledge, (2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.
Jennifer Ziegler, CMRS
Velocity Medical Billing LLC